"It's a totally broken system right now. It is not working well not only in Alabama, it's not working well anywhere," Bentley said of Medicaid.

Gov. Robert Bentley announced last week that he would not, at least for now, expand Medicaid under the Affordable Care Act. Tamika Moore

MONTGOMERY, Alabama -- Gov. Robert Bentley said that he wants to see cost-saving measures, more flexibility for the state or both before he will pull the trigger on any expansion of Alabama's Medicaid program.

Bentley announced last week that he will not expand Medicaid under the federal Affordable Care Act -- which could provide insurance to more than 200,000 uninsured Alabamians -- saying that it would be too costly for the state's already ailing Medicaid program.

But the governor's decision came with a qualifier that he would not expand Medicaid "as it exists under the current structure."

So what structural changes would it take? Significant ones, apparently.

"It's a broken system. It's a totally broken system right now. It is not working well, not only in Alabama, it's not working well anywhere," Bentley said this week of Medicaid.

Bentley pointed to the commission's work when asked what changes he would want to see.

"I have appointed a very good commission to study the amount of money that we get at the present time. ... Whether or not we need a managed care type scenario, they will recommend that to me," Bentley said.

Bentley said he would also like to see changes on the federal level including the adoption of proposals to cut Medicaid spending by turning it into a block grant program.

"Give us some flexibility on the maintenance of effort, whether or not we can change eligibility and co-pays and things of this nature. They give absolutely no leeway, and they are going to have to," Bentley said.

The U.S. Supreme Court, when it upheld the Affordable Care Act, ruled that states could not be forced to expand Medicaid.

A suggested expansion would open up Medicaid to those with household incomes up to 133 percent of the poverty level (although the first 5 percent is disregarded), or about $31,000 for a family of four. That could provide insurance to hundreds of thousands of Alabamians, although estimates on the exact number have varied.

The federal government would pay 100 percent of the cost of services for
new enrollees for the first three years, but that eventually would drop
to 90 percent.

In Alabama about 351,000 people, including 244,804 previously uninsured, could join Medicaid under an expansion, according to 2010 estimates from the Henry J. Kaiser Family Foundation.

A study by the University of Alabama at Birmingham estimated that between 246,219 and 301,799 people would join the Medicaid rolls, according to the Alabama Medicaid Agency.

The Urban Institute estimated that Alabama would rank within the top 20
states for the number of people that would become eligible for
Medicaid.

Advocates of the expansion have said the Affordable Care Act is a
historic opportunity to bring health insurance to people at a cost to
the state of a dime on a dollar.

"He should know better being a physician," Ford said. "We've got a lot of people without insurance in the state of Alabama."

Ford said the expansion would bring coverage to the uninsured, and it would also bring federal dollars to the state's entire healthcare system.

State Republicans, who cheered Bentley's decision, noted that the state is struggling to fund Medicaid as it exists now.

Speaker of the House Mike Hubbard, R-Auburn, said this summer that the 90-10 match is not a bargain if ''you can't afford the 10.''

Kaiser estimated Alabama would have to kick in an extra $470 million to $693 million cumulatively between fiscal years 2014 and 2019 while adding $10 billion in new federal healthcare dollars for Medicaid during the same time period.

Medicaid already consumes about one-third of the state's $1.68 billion General Fund budget. The General Fund appropriation does not account for all state spending on Medicaid

Rosemary Blackmon, executive vice president of the Alabama Hospital Association, said the organization understood the governor's concern about expanding Medicaid but also hoped they could revisit the subject as reforms developed.

"While hospitals understand the importance of health care coverage to the health of our population, we also understand the governor's hesitation about expanding Medicaid in its current form," Blackmon said.

"We are working with the governor's office and with the Medicaid Stakeholder Commission to look at the reforms needed in terms of access, coordination of care and administration. Hospitals hope that as the reform initiatives develop, we can consider the appropriateness of expanding the program in the future," Blackmon said.

States do not face a deadline on the Medicaid expansion and can choose to expand at any time under the Affordable Care Act.

Medicaid is already a major provider of medical services for children, the aged and disabled in the high-poverty state.

There are 940,722 people in Alabama currently enrolled in Medicaid, according to the Alabama Medicaid Agency. While the state has struggled with Medicaid funding, Alabama also runs a bare bones program with few optional services. There are few adults who are not elderly or disabled on Medicaid.

Medicaid pays for about two-thirds of nursing home stays, a little more than half of all maternity deliveries and the medical care of more than 40 percent of the state's children, according to the state Medicaid Agency.

Rank

State

Number of people newly eligible for Medicaid under expansion

1

California

1,873,000

2

Texas

1,748,000

3

Florida

1,295,000

4

Georgia

684,000

5

North Carolina

587,000

6

Ohio

578,000

7

Michigan

564,000

8

Illinois

522,000

9

Pennsylvania

520,000

10

Indiana

374,000

11

Tennessee

361,000

12

Missouri

351,000

13

Virginia

342,000

14

Louisiana

330,000

15

Alabama

321,000

16

Washington

308,000

17

New Jersey

307,000

18

South Carolina

297,000

19

Kentucky

288,000

20

Oregon

252,000

21

Mississippi

231,000

22

Colorado

225,000

23

Oklahoma

225,000

24

Arkansas

218,000

25

Wisconsin

181,000

26

New York

170,000

27

Maryland

167,000

28

Nevada

163,000

29

Kansas

141,000

30

West Virginia

131,000

31

Minnesota

130,000

32

New Mexico

127,000

33

Idaho

108,000

34

Iowa

106,000

35

Utah

105,000

36

Arizona

89,000

37

Connecticut

88,000

38

Massachusetts

88,000

39

Nebraska

78,000

40

Montana

59,000

41

New Hampshire

51,000

42

Maine

46,000

43

Alaska

41,000

44

South Dakota

40,000

45

Rhode Island

38,000

46

Hawaii

37,000

47

North Dakota

24,000

48

Wyoming

24,000

49

District of Columbia

17,000

50

Delaware

9,000

51

Vermont

1,000

Source: Urban Institute

A study by the University of Alabama at Birmingham estimated that between 246,210 and 301,799 people would be added to the Medicaid rolls in Alabama.

The federal government would pay 100 percent of the cost of services for new enrollees for the first three years, but that eventually would drop to 90 percent.

"He should know better being a physician .. We've got a lot of people without insurance in the state of Alabama," Ford said.

Ford said the expansion would bring health insurance to those who don't have it, but also bring in an influx of federal dollars to the state's healthcare system.

Advocates of the expansion have said the Affordable Care Act is a historic opportunity to bring health insurance to people at a cost to the state of a dime on a dollar.

But state Republicans have noted that the state is struggling to fund Medicaid as it exists now.

Speaker of the House Mike Hubbard said this summer that the 90-10 match is not a bargain if ''you can't afford the 10.''

Rosemary Blackmon, executive vice president of the Alabama Hospital Association said her organization understood the governor's concern about expanding Medicaid but hoped they could revisit the subject as reforms developed.

"While hospitals understand the importance of health care coverage to the health of our population, we also understand the governor's hesitation about expanding Medicaid in its current form," Blackmon said.

"We are working with the governor's office and with the Medicaid Stakeholder Commission to look at the reforms needed in terms of access, coordination of care and administration. Hospitals hope that as the reform initiatives develop, we can consider the appropriateness of expanding the program in the future," Blackmon said.

Medicaid is already a major provider of medical services in the high-poverty state.

There are 940,722 people in Alabama currently enrolled in Medicaid, according to the Alabama Medicaid Agency. While the state has struggled with Medicaid funding, Alabama also runs a bare bones program with few optional services. There are few adults who are not elderly or disabled on Medicaid.

Medicaid pays for about two-thirds of nursing home stays, a little more than half of all maternity deliveries and the medical care of more than 40 percent of the state's children, according to the state Medicaid Agency.